The  University  Dakota 

DEPARTMENT  B$!]LGLflTINS 


SMALLPOX 


The  Public  Health  Laboratories 

Bulletin  No.  23 


Entered  as  second  class  matter  at  University,  North  Dakota. 
Acceptance  for  mailing  at  a special  rate  of  postage  provided 
for  in  Section  1103.  Act  of  October  3,  1917,  authorized 
May  5.  1920. 


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NORTH  DAKOTA  STATE  DEPARTMENT  OF  HEALTH 


Hon.  William  E.  Langer,  Bismarck President 

H.  O.  Cooperman,  M.  D.,  Minto Vice  President 

C.  J.  McGurren,  M.  D.,  Devils  Lake Secretary 


DIVISION  OF  VENEREAL  DISEASE  CONTROL 
F.  R.  Smyth,  M.  D.,  Bismarck Director 

DIVISION  OF  LABORATORIES 

A.  G.  Long,  M.  D.,  University Director 

A.  G.  Long,  M.  D Pathologist 

Miss  Caroline  M.  Steele,  B.  S.  . . .Bacteriologist  and  Sereologist 

Miss  Maude  S.  Virden  Stenographer 

I.  W.  Mendelsohn,  B.  S Chemist 


DIVISION  OF  SANITATION 

I.  W.  Mendelsohn,  B.  S.,  University Sanitary  Engineer 

BRANCH  LABORATORIES 

Miss  Delia  Johnson,  B.  A.,  Fargo Bacteriologist  in  charge 

E.  M.  Stanton,  Bismarck  Bacteriologist  in  charge 

Chas.  K.  Allen,  B.  S.,  Minot Bacteriologist  in  charge 


SMALLPOX 


There  is  no  knowledge  as  to  the  first  appearance  of  this 
disease  in  Europe,  it  is  believed  that  some  of  the  great  epi- 
demics which  devastated  Athens  in  430  B.  C.  and  the  plague 
of  Antoninus,  which  appeared  in  Italy  in  165  A.  D.,  were 
epidemics  of  smallpox,  but  the  descriptions  are  too  indefinite. 
The  first  medical  description  of  the  disease  comes  from  two 
Arabian  physicians  at  t he  end  of  the  Ninth  century.  Up  to 
the  beginning  of  the  12th  century  the  disease  was  practically 
constant  in  Europe.  In  the  13th  century  the  disease  became  a 
plague  in  England.  Iceland  and  Greenland  were  visited  a l 
intervals  and  the  greater  portion  of  the  population  destroyel 
several  times.  It  was  introduced  to  America  in  1507  and  has 
never  disappeared  since  being  particularly  active  in  the 
destruction  of  the  native  population.  Smallpox  was  perhaps 
never  more  prevalent  than  in  the  18th  century  when  the 
mortality  was  incredible. 

Vaccination  was  introduced  in  the  19th  century  and  since 
then  the  frequency  and  mortality  of  the  disease  has  begun  -to 
diminish.  Compulsory  vaccination  was  begun  in  Germany  hi 
1874.  The  disease  flourishes  equally  as  well  in  the  tropics  as 
in  the  frozen  north  and  the  entire  human  race  is  susceptible. 

Just  how  infection  takes  place  is  unknown,  but  it  is  thought 
that  the  virus  lodges  in  the  mucous  membrane  of  the  respira- 
tory tract  of  the  susceptible  individual  and  produces  a lesion 


similar  to  that  appearing  on  the  skin.  The  development  takes 
12  days,  then  the  parasites  which  have  developed  entetf  the 
circulating  blood  producing  a fever.  They  then  travel  to  all 
parts  of  the  body  but  only  find  suitable  conditions  for  develop- 
ment in  the  superficial  layers  of  the  skin. 

In  the  past  only  five  persons  out  of  a hundred  escaped  it 
and  about  a quarter  of  those  who  took  it  died  from  its  effects. 
Today,  by  the  simple  and  safe  process  of  vaccination,  the 
disease  may  be  prevented  in  any  community,  and  its  occurrence 
is  always  a mark  of  ignorance  or  neglect  on  the  part  of  the 
victim  or  of  his  associates  and  a sign  that  he  desires  to  wear  a 
“waffle  iron”  face  for  the  rest  of  his  life. 

The  disease  most  likely  to  be  mistaken  for  smallpox  is 
chicken-pox.  The  disease  may  begin  with  gradually  rising 
temperature  and  some  severe  symptoms  lasting  several  days 
before  the  eruption  appears.  In  smallpox  the  temperature 
arises  abruptly  and  just  as  the  eruption  is  coming  out  or  before 
it  is  out,  it  drops  abruptly. 

In  chicken-pox  the  rise  is  gradual  and  is  maintained  after 
the  eruption  appears  lasting  for  a day  or  so.  The  paucity 
of  eruption  is  sometimes  a pitfall.  Smallpox  very  often  pre- 
sents a much  more  profuse  eruption  than  chicken-pox,  however 
these  are  forms  of  rash  which  demand  careful  study.  In 
most  cases  the  lesions  are  abortive ; some  go  no  farther  than 
the  papular  stage ; some  vesicles  dry  before  reaching  a typi- 
cally pustular  stage  ,and  sometimes  the  eruption  goes  through 
all  the  classical  stages  with  the  pustules  in  a diminutive  size. 
Again  the  lesions  of  smallpox  may  be  quite  irregular  in  form 
and  large  areas  of  the  back  or  other  surfaces  may  be  covered 
with  an  eruption  which  is  superficial  and  not  indurated. 

There  is  no  one  thing  upon  which  we  may  safely  pin  our 
faith  in  the  diagnosis  of  smallpox,  while  we  may  be  reasonably 
certain  of  our  diagnosis  we  should  take  into  consideration  the 
patient’s  history  as  to  previous  childhood  illness  ; temperature 
curve ; signs  of  successful  vaccination ; characteristic  course 
and  location  of  the  eruption. 


The  most  important  points  in  diagnosis  between  smallpox 
and  chicken-pox  may  be  summarized  as  follows : 

1.  In  smallpox  the  prodromal  symptoms  before  the  erup- 
tion appears  usually  last  about  three  days,  but  they  may  last 
longer,  four  or  five,  or  rarely  six  days,  or  may  be  no  more  than 
one  day.  In  eliicken-pox  there  is  usually  no  distinct  prodromal 
period.  - The  eruption  is  often  the  first  thing  noticed. 

2.  In  smallpox  the  onset  of  the  prodromal  symptoms  is 
abrupt.  When  there  is  a marked  systemic  disturbance  in 
chicken-pox  the  onset  of  the  symptoms  is  much  less  abrupt 
and  they  usually  persist  after  the  eruption  appears. 

3.  In  smallpox  there  is  a marked  fall  in  temperature  with 
the  appearance  of  the  eruption,  or  very  soon  after,  or  even 
before  the  eruption  shows  itself,  and  in  cases  with  a sparse 
eruption  there  is  no  subsequent  rise— there  is  no  secondary 
fever.  In  chicken-pox  with  distinct  systemic  symptoms  the 
temperature  does  not  fall  with  the  appearance  of  the  vesicles: 
it  may  remain  at  101°  or  102°F.  or  more  for  24  or  48  hours  or 
so  after  the  onset  of  the  eruptive  stage  with  a distinct  rise  with 
each  fresh  crop  of  vesicles. 

4.  Aside  from  the  macular  stage,  the  eruption  of  smallpox 
first  appears  as  papules ; in  chicken-pox  as  vesicles. 

5.  In  smallpox,  before  encrustation  occurs,  the  lesions  pass 
through  the  stages  of  papulation,  vesiculation  and  pustulation. 
In  chicken-pox  the  lesions  appear  as  vesicles  and  dry  down  as 
vesicles  with  turbid  contents — no  true  pustules. 

G.  In  smallpox  the  lesions  are  not  well  rounded  up  as 
vesicles,  but  as  pustules  they  are  semiglobular.  In  chicken-pox 
the  vesicles  are  well  rounded  out  at  first,  but  flatten  down 
before  a true  pustular  starge  is  reached. 

# 

7.  In  smallpox  abnormailities  are  frequent,  and  the  erup- 
tion sometimes  goes  through  its  transformation  with  remark- 
able clerity,  but  the  typical  lesions  before  desiccation  begins 
are  p pules  about  two  d ys,  vesicles  two  days,  and  pustules 


four  days.  In  cliicken-pox  the  vesicles  begin  to  dry  down  in 
twenty-four  or  thirty-six  hours. 

8.  Flatwise  of  the  skin  the  smallpox  lesions  rarely  depart 
but  little  from  the  true  circular  in  outline.  In  chicken-pox 
many  of  the  lesions  are  oval  or  irregular  in  outline. 

9.  The  smallpox  papule  is  indurated.  It  has  the  sliotty 
feel,  and  the  vesicle  has  a distinctly  indurated  base.  In 
chicken-pox  there  is  no  distinct  induration. 

10.  In  the  distribution  of  the  eruption  of  smallpox  there 
is  likely  to  be  the  greatest  profusion  on  the  face,  and  it  is 
most  scanty  on  the  chest  and  abdomen.  In  chicken-pox  it  is  as 
abundant  on  the  abdomen  and  chest  as  on  the  face,  and  often 
more  so. 

11.  In  smallpox  there  is  a more  abundant  eruption  on  the 
back  than  on  the  abdomen.  In  chicken-pox  a marked  difference 
is  not  the  rule. 

12.  In  smallpox  there  is  a diminishing  graduation  from 
the  shoulders  to  the  loins,  and  fro  rathe  chest  to  the  lower  part 
of  the  abdomen.  No  such  rule  is  followed  in  the  distribution 
of  the  eruption  of  chicken-pox. 

13.  In  smallpox  the  eruption  is  usually  more  abundant  on 
the  limbs  than  on  the  trunk.  In  chicken-pox  it  tends  to  avoid 
the  limbs. 

14.  In  smallpox  the  eruption  is  more  abundant  on  the  dis- 
talends  of  the  limbs.  In  chicken-pox  it  is  more  abundant  on 
the  proximal  ends. 

15.  In  smallpox  the  eruption  is  most  profuse  on  the  parts 
which  are  most  prominent  and  are  the  most  exposed' to  the  air 
or  to  irritating  influences,  and  is  most  sparse  in  the  depressions 
and  flextures.  In  chicken-pox  no  such  law  controls  the  dis- 
tribution. 

1<>.  Chicken-pox  is  rarely  seen  in  adults. 


Unmodified  smallpox  is  usually  one  of  the  most  fatal  and 
loathesome  of  diseases.  Vaccination  in  childhood  almost 
always  prevents  a fatal  result  even  if  the  disease  is  contracted 
in  old  age.  Vaccination,  recently  and  properly  done,  will  pre- 
vent, almost  without  exception,  the  contraction  of  smallpox, 
no  matter  how  great  the  exposure.  It  is  the  usual  thing  to  find! 
tliata  the  community  with  a smallpox  outbreak  on  its  hands 
is  one  in  which  there  is  no  compulsory  vaccination,  and  that 
but  a very  small  percentage  of  the  community  have  availed 
themselves  of  this  protection.  The  more  usual  thing  is  a com- 
munity apathetic  as  regards  smallpox  until  the  disease  appears 
and  has  spread  to  dangerous  proportions.  Statistics  compiled 
by  observers  in  various  parts  of  the  world,  all  tell  the  same 
story,  namely,  that  92.5  percent  of  smallpox  occurs  in  the 
un  vaccina  ted. 

Every  person  should  be  vaccinated  when  an  infant  and  then 
re-vaccinated  at  regular  intervals  as  it  has  been  found  that 
successful  vaccination  on  two  occasions  usually  confers  a life 
long  immunity  which  is  as  nearly  absolute  as  anything  can  he 
in  this  world. 

Through  the  introduction  of  bovine  virus  it  is  absolutely 
impossible  to  transmit  any  disease  from  person  to  person,  and, 
if  due  care  of  the  wound  is  taken,  it  is  not  possible  for  tetanus 
to  develop  as  that  germ  has  never  been  found  in  the  vaccine 
itself. 

Vaccination  should  be  performed  by  no  one  but  an  experi- 
enced physician  and  one  of  the  methods  advised  by  the  Surgeon- 
General  of  the  United  States  Public  eHaltli  Service  is  as 
follows.  It  is  known  as  the  endermic  or  multiple  puncture 
method : 

(1)  The  vaccination  site,  near  the  insertion  of  the  deltoid, 
may  be  washed  with  soap  and  water  and  then  should  be 
washed  with  alcohol  or  ether.  (2)  After  the  skin  has  dried 
a moment,  a small  drop  of  vaccine  is  deposited  upon  the  skin 
at  three  spots,  forming  a triangle  whose  points  are  not  less 
than  two  inches  apart.  (3)  An  ordinary  sewing  needle  of 
pretty  good  size,  with  a sharper  point  than  those  which  usually 


come  with  the  tubes  of  vaccine,  is  sterilized.  Needles  are 
much  more  conveniently  used  if  mounted  in  wooden  handles, 
or  pushed  into  penholders  as  substitutes.  (4)  The  vaccinator’s 
hand,  closed  upon  the  arm  from  behind,  draws  the  skin  tense 
in  front.  The  needle,  held  slantingly,  but  nearly  parallel  with 
the  arm.  is  pressed  against  the  skin  through  the  drop  of  vac- 
cine. About  ten  tiny  punctures  should  be  made  through  each 
droplet  of  vaccine,  each  set  of  ten  punctures,  covering  an  area 
of  not  more  than  one-sixth  of  an  inch  square.  The  punctures 
should  not  draw7  blood ; they  should  in  fact,  be  hardly  one  one- 
hundredtli  inch  deep.  (5)  The  surface  is  wiped  with  a bit  of 
sterile  gauze  or  cotton  and  the  sleeve  is  drawn  down. 

There  is  no  need  of  the  application  of  bandages  or  any 
kind  of  dressings  : it  is  really  better  not  to  resort  to  anything 
of  the  kind,  unless,  possibly,  a square  of  sterile  gauze  is 
attached  by  needle  and  thred  or  by  safety  pins  to  that  part  of 
the  sleeve  covering  the  place  of  vaccination. 

The  advantages  of  this  method  are:  (1)  The  vaccinations 
may  rapidly  and  easily  be  done.  (2)  It  is  bloodless,  painless 
and,  therefore,  not  so  objectionable  to  timid  persons.  (3)  The 
chances  for  sore  arms  and  other  undesirable  results  are  reduced 
to  a minimum.  (4)  There  is  a saving  of  band  ges  and  other 
-dressings  an  dof  time  in  applying  them.  (5)  The  percentage 
of  takes  is  as  good  or  better  than  with  other  methods. 

As  smallpox  is  contagious  from  the  time  the  eruption  first 
appears,  until  after  it  has  entirely  disappeared  and  until 
scaling  has  ceased,  the  affected  person  should  be  isolated  from 
all  but  necessary  attendants.  He  should  be  removed  to  a 
hospital  if  possible.  If  treated  at  home  strict  isolation  is 
needed,  all  contacts  and  attendants  should  be  freshly  vac- 
cinated. A placard  with  smallpox  in  large  plain  letters  should 
be  posted  in  a conspicuous  place.  The  advantages  of  vaccina- 
tion of  contacts  are  numerous, — it  will  prevent  the  develop- 
ment of  smallpox  if  performed  soon  enough : it  will  modify 
the  course  of  the  disease  if  not  performed  soon  enough ; and, 
finally,  it  wTill  allow  the  contacts  to  go  about  their  business, 
but  they  should  report  for  inspection  daily  for  20  days. 


\ 


As  the  disease  is  very  contagious  and  may  be  conveyed  by 
persons,  clothing,  letters,  it  is  advisable  to  keep  everything 
away  from  the  patient  except  what  is  absolutely  necessary,  to 
receive  all  discharges  into  old  rags  which  can  be  burned  or 
into  vessels  containing  some  good  disinfectant  such  as  5 per 
cent  carbolic  acid  or  2 percent  creolin.  Eating  utensils  should 
also  be  wet  in  5 percent  carbolic  acid  when  removed  from  the 
bed  and  allowed  to  stand  two  hours  and  then  boiled.  During 
the  scabbing  and  scaling  stage  the  patient  should  have  his 
body  annointed  with  oil  or  vaseline  and  the  floors  mopped  daily 
with  carbolic  acid  solution.  When  the  patient  is  ready  to 
dismiss  he  should  be  given  a carbolic  or  1-5000  bichloride  bath 
and  his  hair  well  washed  also.  He  should  go  into  another 
room  to  dress  and  put  on  all  clean  clothes,  his  old  ones  being 
carefully  disinfected  before  being  washed. 

The  quarters  where  the  patient  has  been  treated  should 
be  carefully  disinfected  and  cleaned  according  to  the  most 
approved  methods.  The  care  with  which  the  latter  is  done  is 
perhaps  of  greate  rvalue  than  the  former.  Of  the  gaseous  dis- 
infestants  formalin  or  sulphur  may  be  used,  the  formalin  being 
perhaps  the  less  injurious  to  fabrics  and  metals.  In  either 
case  the  room  should  be  tightly  closed,  the  temperature  of  at 
least  ()0°F  and  the  air  very  moist  and  the  gas  allowed  to  act 
eight  to  twelve  hours,  when  the  room  may  be  opened  and  the 
floor,  woodwork,  walls  and  ceiling  washed  down.  If  the  person 
dies,  there  can  be  no  public  funeral.  The  patient  must  remain 
in  quarantine  till  all  lesions  have  disappeared. 

As  home  treatment  of  smallpox  is  difficult,  it  is  advisable 
to  establish  a hospital  owned  by  the  municipality  and  under  the 
control  of  the  health  department,  such  an  institution  could 
serve  several  adjoining  districts,  who  could  unite  in  bearing 
the  cost  of  erection  and  maintenance.  Such  hospitals  could 
be  rendered  entirely  non-infectious  and  could  be  used  for  any 
communicable  disease.  It  is  not  absolutely  necessary  to  have 
the  building  in  an  inaccessible  situation  as  long  as  it  is  some 
300  feet  from  any  roadway  or  other  building.  The  hospital 
should  be  supplied  with  a vehicle  which  can  be  used  as  an 


ambulance,  should  have  means  for  sterilizing  and  disinfecting 
clothing,  and  some  efficient  means  of  disposing  of  excreta. 
A resident  matron  is  necessary,  also  provision  should  be  made 
for  obtaining  extra  assistance  as  occasion  demands.  The 
building  should  be  attractively  built  and  kept  in  good  repair 
so  that  patients  will  no*t  object  to  being  placed  there.  The 
grounds  should  be  sufficiently  large  in  order  that  convalescent 
patients  may  exercise  in  the  fresh  air,  move  around  without 
coming  into  too  direct  contact  with  the  public. 

If  smallpox  occurs  in  a school,  don’t  stop  the  school,  stop 
the  student  who  has  it  and  all  the  other  children  in  the  family. 
Vaccinate  all  who  have  not  been  vaccinated  at  once,  and  carry 
on  just  as  if  nothing  had  happened.  If  vaccination  were  com- 
pulsory there  would  be  no  smallpox  in  North  Dakota  after  the 
present  generation,  except  imported  cases. 

The  regulations  of  the  State  Department  of  Health  in 
regard  to  smallpox  are  as  follows : 

Regulation  10.  (A)  House  must  be  placarded.  The  State 

Board  of  Health  does  not  require  an  absolute  quarantine  for 
smallpox,  being  convinced  that  vaccination  is  the  only  rational 
method  of  preventing  this  disease.  The  requirements  of  the 
State  Board  of  Health  are : When  a case  of  smallpox  is 
reported  to  a health  officer  he  shall  place  a sign  bearing  the 
words  “Smallpox  Here”  on  each  entrance  to  the  house  where 
the  disease  exists.  Any  person  suffering  from  smallpox  is 
prohibited  from  leaving  the  premises  until  desquamation  is 
completed. 

(B)  Cities  and  Counties  May  Quarantine.  Cities  have 
authority  to  pass  ordinances  and  county  boards  of  health  may 
make  regulations  requiring  more  rigid  quarantine  for  small- 
pox, but  until  such  ordinances  have  been  enacted  and  until 
such  regulations  have  been  adopted  by  the  county  board  of 
health  and  approved  by  the  State  Board  of  Health,  no  local  or 
county  health  officer  has  authority  to  enforce  more  rigid 
quarantine  for  smallpox  than  is  provided  under  Rergulation 
10.  Par.  A. 


FREE  BULLETINS  FOR  CITIZENS — ASK  FOR  THEM 


1.  State  Public  Health  Laboratory.  History,  Instructions 
and  Fee  Table. 

*2.  What  You  Should  Know  About  Tuberculosis. 

3.  Pure  Water  and  How  to  Obtain  It. 

*4.  Sporotrichosis  in  North  Dakota. 

*5.  Facts  About  Rabies. 

6.  The  Production  and  Care  of  Milk  for  Infant  Feeding. 
*7.  Facts  About  Cancer. 

8.  The  Fly;  a Disease  Carrier. 

9.  Ninth  Annual  Report  of  State  Public  Health  Labora- 

tories. 

10.  The  Sanitary  Privy. 

11.  Your  Baby,  How  to  Keep  it  Well. 

12.  The  Next  Step  Towards  Efficiency  in  Public  Health. 

13.  Fresh  Air  and  Why.  A talk  on  school-room  ventilation. 

14.  Colds.  Cause,  Prevention  and  Home  Treatment. 

15.  Cerebro  Spinal  Meningitis. 

16.  Keeping  in  Repair.  How  to  care  for  the  body — Physical 

Examinations. 

17.  Scarlet  Fever.  How  it  may  be  detected.  How  it  may 

be  avoided.  Directions  to  mothers,  nurses,  physicians 
and  health  officers  for  treating  cases  of  this  disease. 

18.  Disinfection  and  Disinfectants. 

19.  The  Teacher  and  Communicable  Disease. 

How  disease  is  caused  and  spreads,  symptoms  by  which 
the  teacher  may  detect  communicable  disease. 

20.  Diphtheria.  Cause,  prevention  and  cure. 

21.  Typhoid  Fever.  Information  for  those  who  care  for 

patient,  for  physician  and  health  officers  in  regard 
to  the  spread  and  prevention  of  typhoid  fever. 


22.  Measles  and  Whooping  Cough.  Information  for  parents 

and  for  those  who  care  for  the  patient,  for  physicians 
and  health  officers  in  regard  to  spread  and  prevention 
of  measles  and  whooping  cough. 

23.  Smallpox.  How  to  detect  this  loathsome  disease.  How 

the  disease  spreads,  an  dhow  it  may  be  avoided. 
Direction  for  care  of  patients. 

24.  The  Wasserman  Reaction  as  a diagnostic  procedure. 

Interpretation.  Need  for  a history.  Provocative 
Wasserman. 

25.  Health  Officer’s  Loan  Library. 

*26.  Stereopticon  Loan  Library. 

*27.  Rural  Home  Comforts.  A series  of  four  blue  prints 
together  with  specifications  dealing  with  the  subject 
of  septic  tank  and  sewage  disposal. 

28.  Influenza. 


Not  in  print 


